Stroke - A Comprehensive Overview

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pres.author = "Orris Medical";
pres.title = "Stroke - A Comprehensive Overview";

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// ════════════════════════════════════════════════════════════════
//  SLIDE 1 — TITLE SLIDE
// ════════════════════════════════════════════════════════════════
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// ════════════════════════════════════════════════════════════════
//  SLIDE 2 — TABLE OF CONTENTS
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Table of Contents");

  const topics = [
    ["01", "Definition & Epidemiology"],
    ["02", "Classification of Stroke"],
    ["03", "Pathophysiology"],
    ["04", "Etiology of Ischemic Stroke"],
    ["05", "Risk Factors"],
    ["06", "Clinical Features & Syndromes"],
    ["07", "Diagnosis & Imaging"],
    ["08", "Acute Management - Ischemic Stroke"],
    ["09", "Acute Management - Hemorrhagic Stroke"],
    ["10", "Secondary Prevention"],
    ["11", "Complications"],
    ["12", "Rehabilitation & Prognosis"],
  ];

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// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: OVERVIEW
// ════════════════════════════════════════════════════════════════
sectionSlide("01  Definition & Epidemiology", "What is a stroke and why does it matter?");

// ════════════════════════════════════════════════════════════════
//  SLIDE 3 — DEFINITION & EPIDEMIOLOGY
// ════════════════════════════════════════════════════════════════
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  slide.addText(
    "A stroke (cerebrovascular accident, CVA) is the sudden onset of a focal neurological deficit caused by disruption of cerebral blood supply, either due to ischemia or hemorrhage, lasting >24 hours or causing death.",
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    { val: "#1", label: "Leading cause of\nadult disability", color: C.navyLight },
    { val: "87%", label: "Ischemic strokes\n(majority)", color: C.tealDark },
    { val: "13%", label: "Hemorrhagic\nstrokes", color: C.orange },
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    "Transient episode of neurological dysfunction caused by focal ischemia WITHOUT infarction on imaging. High short-term stroke risk — now tissue-based (not time-based) definition.",
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// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: CLASSIFICATION
// ════════════════════════════════════════════════════════════════
sectionSlide("02  Classification of Stroke", "Ischemic vs. Hemorrhagic");

// ════════════════════════════════════════════════════════════════
//  SLIDE 4 — CLASSIFICATION
// ════════════════════════════════════════════════════════════════
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  const iTypes = [
    ["Large Vessel", "Atherosclerosis of major cerebral arteries (ICA, MCA, basilar)"],
    ["Small Vessel\n(Lacunar)", "Lipohyalinosis of small penetrating arteries; <1.5 cm infarcts"],
    ["Cardioembolic", "Atrial fibrillation, mural thrombus, valve disease"],
    ["Cryptogenic", "No identifiable cause despite full workup (~25–30%)"],
    ["Other", "Dissection, hypercoagulable states, vasculitis, moyamoya"],
  ];
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    ["Intracerebral\nHemorrhage (ICH)", "Spontaneous bleeding into brain parenchyma; hypertension most common cause"],
    ["Subarachnoid\nHemorrhage (SAH)", "Bleeding into subarachnoid space; ruptured saccular aneurysm (#1 cause)"],
    ["Cerebral Amyloid\nAngiopathy (CAA)", "Amyloid deposition in vessel walls; lobar hemorrhages in elderly"],
    ["Secondary ICH", "AVM, tumor, venous sinus thrombosis, hemorrhagic transformation"],
  ];
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// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: PATHOPHYSIOLOGY
// ════════════════════════════════════════════════════════════════
sectionSlide("03  Pathophysiology", "The ischemic cascade & hemorrhagic injury");

// ════════════════════════════════════════════════════════════════
//  SLIDE 5 — PATHOPHYSIOLOGY: ISCHEMIC
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Pathophysiology — Ischemic Stroke");

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    { cbf: "16–18", label: "Electrical silence", sub: "Neurons viable but not firing — PENUMBRA", color: C.orange },
    { cbf: "<10", label: "Membrane failure", sub: "K⁺ efflux, Ca²⁺ influx → cell death → INFARCT CORE", color: C.red },
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  // Penumbra concept
  const zones = [
    { label: "Infarct Core", sub: "CBF <10\nIrreversible damage\nDeath within minutes", color: C.red, x: 0.25 },
    { label: "Ischemic Penumbra", sub: "CBF 10–18\nVIABLE but at risk\nPrimary therapeutic target", color: C.orange, x: 3.55 },
    { label: "Oligemia / At Risk", sub: "CBF slightly reduced\nClinically silent\nMay progress without Rx", color: C.yellow, x: 6.85 },
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// ════════════════════════════════════════════════════════════════
//  SLIDE 6 — PATHOPHYSIOLOGY: HEMORRHAGIC
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Pathophysiology — Hemorrhagic Stroke");

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    { text: "Lipohyalinosis", options: { bold: true } },
    { text: " of small penetrating arteries from chronic hypertension\n", options: {} },
    { text: "• Deep brain structures affected: putamen (44%), thalamus (13%), pons (9%), cerebellum (9%)\n", options: {} },
    { text: "• Results in microaneurysm formation (Charcot-Bouchard) → rupture", options: {} },
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  slide.addText([
    { text: "• Amyloid-β deposition in cortical and leptomeningeal vessel walls\n", options: {} },
    { text: "• Causes ", options: {} },
    { text: "lobar hemorrhages", options: { bold: true } },
    { text: " in elderly patients\n", options: {} },
    { text: "• Associated with multiple microbleeds on GRE/SWI MRI\n", options: {} },
    { text: "• Recurrent spontaneous lobar ICH = hallmark", options: {} },
  ], { x: 5.3, y: 1.22, w: 4.35, h: 1.55, fontSize: 11, color: C.navy, fontFace: "Calibri" });

  // ICH injury mechanism
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  slide.addText("MECHANISM OF INJURY IN ICH", {
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  const mechs = [
    "① Direct tissue\ndestruction",
    "② Perihematomal\nedema (hours–days)",
    "③ ↑ Intracranial\npressure (ICP)",
    "④ Herniation\n(severe cases)",
    "⑤ Hematoma\nexpansion (24–48h)",
  ];
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  });
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: ETIOLOGY
// ════════════════════════════════════════════════════════════════
sectionSlide("04  Etiology of Ischemic Stroke", "TOAST Classification & common causes");

// ════════════════════════════════════════════════════════════════
//  SLIDE 7 — ETIOLOGY
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Etiology of Ischemic Stroke — TOAST Classification");

  const etiologies = [
    {
      title: "Large Artery Atherosclerosis",
      pct: "~30%",
      color: C.navy,
      points: ["Carotid bifurcation plaque", "Aortic arch atherosclerosis", "Intracranial atherosclerosis", "Mechanism: artery-to-artery embolism or flow-limiting stenosis"],
    },
    {
      title: "Cardioembolism",
      pct: "~30%",
      color: C.red,
      points: ["Atrial fibrillation (most common)", "Mural thrombus post-MI", "Dilated cardiomyopathy", "Valvular disease (mitral stenosis, prosthetic valve)", "Infective endocarditis"],
    },
    {
      title: "Small Vessel / Lacunar",
      pct: "~25%",
      color: C.tealDark,
      points: ["Lipohyalinosis of <200 µm vessels", "Infarcts <1.5 cm ('lacunes')", "Classic syndromes: pure motor, pure sensory, ataxic hemiparesis", "Strong association with HTN + DM"],
    },
    {
      title: "Other Determined Cause",
      pct: "~5%",
      color: C.orange,
      points: ["Arterial dissection (young patients)", "Hypercoagulable states", "Vasculitis / CADASIL / Moyamoya", "Sickle cell disease"],
    },
  ];

  etiologies.forEach((e, i) => {
    const x = 0.25 + (i % 2) * 4.88;
    const y = i < 2 ? 0.85 : 3.02;
    card(slide, x, y, 4.65, 2.0, "FFFFFF", e.color);
    slide.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 4.65, h: 0.35,
      fill: { color: e.color }, line: { color: e.color }
    });
    slide.addText(`${e.title}  (${e.pct})`, {
      x: x + 0.1, y, w: 4.45, h: 0.35,
      fontSize: 11, bold: true, color: C.white,
      fontFace: "Calibri", valign: "middle"
    });
    const bulletItems = e.points.map((p, pi) => ({
      text: p,
      options: { bullet: true, breakLine: pi < e.points.length - 1 }
    }));
    slide.addText(bulletItems, {
      x: x + 0.1, y: y + 0.38, w: 4.45, h: 1.55,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 8 — RISK FACTORS
// ════════════════════════════════════════════════════════════════
sectionSlide("05  Risk Factors", "Modifiable and non-modifiable");
{
  const slide = contentSlide("Risk Factors for Stroke");

  // Non-modifiable
  card(slide, 0.25, 0.85, 4.55, 3.0, "F5F5F5", C.grayDark);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 0.85, w: 4.55, h: 0.38,
    fill: { color: C.grayDark }, line: { color: C.grayDark }
  });
  slide.addText("NON-MODIFIABLE", {
    x: 0.25, y: 0.85, w: 4.55, h: 0.38,
    fontSize: 13, bold: true, color: C.white,
    fontFace: "Calibri", align: "center", valign: "middle"
  });
  const nonMod = ["Age (risk doubles every decade after 55)", "Male sex", "Race (higher in Black, Hispanic populations)", "Family history / genetics", "Prior stroke or TIA"];
  nonMod.forEach((item, i) => {
    slide.addText(`• ${item}`, {
      x: 0.4, y: 1.32 + i * 0.48, w: 4.25, h: 0.44,
      fontSize: 12, color: C.navy, fontFace: "Calibri"
    });
  });

  // Modifiable
  card(slide, 5.2, 0.85, 4.55, 4.3, "FFFFFF", C.red);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 5.2, y: 0.85, w: 4.55, h: 0.38,
    fill: { color: C.red }, line: { color: C.red }
  });
  slide.addText("MODIFIABLE  ⟵  Key to Prevention", {
    x: 5.2, y: 0.85, w: 4.55, h: 0.38,
    fontSize: 12, bold: true, color: C.white,
    fontFace: "Calibri", align: "center", valign: "middle"
  });
  const modItems = [
    ["Hypertension", "Most important modifiable risk factor"],
    ["Atrial Fibrillation", "5x increased stroke risk; anticoagulation is key"],
    ["Diabetes mellitus", "2–3x increased risk; poor glycemic control worsens outcome"],
    ["Dyslipidemia", "LDL lowering with statins reduces risk"],
    ["Smoking", "2x risk; cessation rapidly reduces risk"],
    ["Carotid stenosis", "Symptomatic stenosis ≥50–70% — consider CEA"],
    ["Obesity & Inactivity", "Metabolic syndrome increases risk"],
  ];
  modItems.forEach((item, i) => {
    slide.addText(item[0], {
      x: 5.35, y: 1.32 + i * 0.52, w: 2.1, h: 0.28,
      fontSize: 11, bold: true, color: C.red, fontFace: "Calibri"
    });
    slide.addText(item[1], {
      x: 5.35, y: 1.57 + i * 0.52, w: 4.25, h: 0.25,
      fontSize: 10, color: C.grayDark, fontFace: "Calibri"
    });
  });

  // ABCD2 note
  card(slide, 0.25, 4.0, 4.55, 0.62, "EAF4FF", C.navyLight);
  slide.addText("ABCD² Score: predicts short-term stroke risk after TIA (Age, BP, Clinical features, Duration, Diabetes)", {
    x: 0.38, y: 4.03, w: 4.3, h: 0.56,
    fontSize: 10, color: C.navyLight, fontFace: "Calibri"
  });
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: CLINICAL FEATURES
// ════════════════════════════════════════════════════════════════
sectionSlide("06  Clinical Features", "Stroke syndromes by vascular territory");

// ════════════════════════════════════════════════════════════════
//  SLIDE 9 — CLINICAL FEATURES
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Clinical Features — Vascular Territory Syndromes");

  const territories = [
    {
      name: "MCA (Middle Cerebral A.)",
      color: C.navyLight,
      features: ["Contralateral hemiplegia & hemisensory loss (face > arm > leg)", "Contralateral homonymous hemianopia", "Dominant hemisphere: aphasia (Broca/Wernicke)", "Non-dominant: neglect, anosognosia", "Gaze deviation toward lesion"],
    },
    {
      name: "ACA (Anterior Cerebral A.)",
      color: C.tealDark,
      features: ["Contralateral leg > arm weakness", "Urinary incontinence", "Abulia / personality change", "Grasp reflex"],
    },
    {
      name: "PCA (Posterior Cerebral A.)",
      color: C.orange,
      features: ["Contralateral homonymous hemianopia", "Alexia without agraphia (dominant)", "CN III palsy with contralateral hemiplegia (Weber syndrome)", "Contralateral sensory loss (thalamic involvement)"],
    },
    {
      name: "Vertebrobasilar",
      color: C.red,
      features: ["Ipsilateral CN deficits + contralateral hemiparesis (crossed signs)", "Wallenberg (lateral medullary): vertigo, Horner, ipsilateral face numbness, contralateral pain/temp loss", "Basilar artery occlusion: 'locked-in syndrome', coma, death"],
    },
    {
      name: "Lacunar Syndromes",
      color: C.grayDark,
      features: ["Pure motor hemiplegia (posterior internal capsule/pons)", "Pure sensory stroke (thalamus)", "Ataxic hemiparesis", "Dysarthria-clumsy hand syndrome"],
    },
  ];

  territories.forEach((t, i) => {
    const col = i < 3 ? 0 : 1;
    const row = i < 3 ? i : i - 3;
    const x = col === 0 ? 0.25 : 5.15;
    const y = 0.85 + row * 1.47;
    const h = (col === 1 && row === 1) ? 2.1 : 1.38;
    card(slide, x, y, 4.65, h, "FFFFFF", t.color);
    slide.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 4.65, h: 0.3,
      fill: { color: t.color }, line: { color: t.color }
    });
    slide.addText(t.name, {
      x: x + 0.1, y, w: 4.45, h: 0.3,
      fontSize: 11, bold: true, color: C.white,
      fontFace: "Calibri", valign: "middle"
    });
    const bullets = t.features.map((f, fi) => ({
      text: f,
      options: { bullet: true, breakLine: fi < t.features.length - 1 }
    }));
    slide.addText(bullets, {
      x: x + 0.1, y: y + 0.33, w: 4.45, h: h - 0.36,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 10 — HEMORRHAGIC CLINICAL FEATURES + NIHSS
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Clinical Features — Hemorrhagic Stroke & NIHSS");

  // ICH vs Ischemic comparison
  card(slide, 0.25, 0.85, 9.5, 1.5, "FFFFFF", C.navy);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 0.85, w: 9.5, h: 0.32,
    fill: { color: C.navy }, line: { color: C.navy }
  });
  slide.addText("Clinical Clues: ICH vs. Ischemic Stroke", {
    x: 0.35, y: 0.85, w: 9.3, h: 0.32,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });

  const rows = [
    ["Feature", "Ischemic Stroke", "ICH / Hemorrhagic"],
    ["Onset", "Maximal at onset; may remit", "Progressive over minutes–hours"],
    ["Headache", "Absent or mild", "Severe ('thunderclap' in SAH)"],
    ["Vomiting", "Uncommon", "Common"],
    ["Blood Pressure", "Variable", "Markedly elevated"],
    ["Consciousness", "Usually preserved", "Often impaired / declining LOC"],
  ];

  rows.forEach((row, ri) => {
    const y = 1.18 + ri * 0.36;
    const isHeader = ri === 0;
    [row[0], row[1], row[2]].forEach((cell, ci) => {
      const x = ci === 0 ? 0.3 : ci === 1 ? 3.0 : 6.5;
      const w = ci === 0 ? 2.65 : 3.4;
      if (isHeader) {
        slide.addText(cell, {
          x, y, w, h: 0.32,
          fontSize: 10, bold: true, color: ci === 0 ? C.navy : ci === 1 ? C.navyLight : C.red,
          fontFace: "Calibri", align: "center"
        });
      } else {
        slide.addText(cell, {
          x, y, w, h: 0.33,
          fontSize: 10, color: ci === 2 ? C.red : C.navy,
          fontFace: "Calibri", align: ci === 0 ? "left" : "center"
        });
        if (ri % 2 === 0) {
          slide.addShape(pres.shapes.RECTANGLE, {
            x: 0.3, y, w: 9.4, h: 0.33,
            fill: { color: "F0F5FF", transparency: 0 },
            line: { color: "F0F5FF" }
          });
          slide.addText(cell, {
            x, y, w, h: 0.33,
            fontSize: 10, color: ci === 2 ? C.red : C.navy,
            fontFace: "Calibri", align: ci === 0 ? "left" : "center"
          });
        }
      }
    });
  });

  // NIHSS
  card(slide, 0.25, 3.4, 9.5, 1.62, "FFFFFF", C.navyLight);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 3.4, w: 9.5, h: 0.32,
    fill: { color: C.navyLight }, line: { color: C.navyLight }
  });
  slide.addText("NIH Stroke Scale (NIHSS) — Score 0–42", {
    x: 0.35, y: 3.4, w: 9.3, h: 0.32,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });

  const nihssItems = [
    ["1–4", "Minor", C.green],
    ["5–15", "Moderate", C.orange],
    ["16–20", "Mod–Severe", C.redLight],
    ["21–42", "Severe", C.red],
  ];
  nihssItems.forEach((n, i) => {
    const x = 0.4 + i * 2.38;
    slide.addText(n[0], { x, y: 3.78, w: 2.2, h: 0.42, fontSize: 22, bold: true, color: n[2], fontFace: "Calibri", align: "center" });
    slide.addText(n[1], { x, y: 4.2, w: 2.2, h: 0.3, fontSize: 11, color: C.navy, fontFace: "Calibri", align: "center" });
  });
  slide.addText("Assesses: LOC, gaze, visual fields, facial palsy, motor (arm/leg), ataxia, sensation, language, dysarthria, extinction", {
    x: 0.35, y: 4.54, w: 9.3, h: 0.38,
    fontSize: 10, color: C.grayDark, fontFace: "Calibri"
  });
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: DIAGNOSIS
// ════════════════════════════════════════════════════════════════
sectionSlide("07  Diagnosis & Imaging", "Emergency workup and neuroimaging");

// ════════════════════════════════════════════════════════════════
//  SLIDE 11 — DIAGNOSIS
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Diagnosis — Emergency Workup");

  // Imaging modalities
  const imaging = [
    {
      title: "Non-contrast CT Head",
      role: "FIRST-LINE — ALWAYS",
      color: C.red,
      points: ["Immediately identifies hemorrhage", "Free of hemorrhage → thrombolysis eligible", "Ischemic changes lag: 6–12 h for visible infarct", "Early signs: hyperdense artery sign, loss of insular ribbon, gray-white blurring"],
    },
    {
      title: "CT Angiography (CTA)",
      role: "LVO detection",
      color: C.navyLight,
      points: ["Identifies large vessel occlusion (LVO)", "Carotid stenosis, dissection", "Can be obtained concurrently with NCCT", "Essential for thrombectomy triage"],
    },
    {
      title: "CT Perfusion (CTP)",
      role: "Extended window (6–24h)",
      color: C.tealDark,
      points: ["Identifies penumbra vs. infarct core", "DAWN/DEFUSE-3 trial selection criteria", "Not routinely needed in first 6h", "Mismatch = salvageable tissue"],
    },
    {
      title: "MRI (DWI)",
      role: "Most sensitive",
      color: C.orange,
      points: ["DWI detects ischemia within minutes", "Best for posterior fossa/brainstem strokes", "Identifies small lacunes not seen on CT", "GRE/SWI: microbleeds (amyloid angiopathy)"],
    },
  ];

  imaging.forEach((img, i) => {
    const x = 0.25 + (i % 2) * 4.88;
    const y = i < 2 ? 0.85 : 3.1;
    card(slide, x, y, 4.65, 2.08, "FFFFFF", img.color);
    slide.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 4.65, h: 0.32,
      fill: { color: img.color }, line: { color: img.color }
    });
    slide.addText(`${img.title}  ·  ${img.role}`, {
      x: x + 0.1, y, w: 4.45, h: 0.32,
      fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
    });
    const bullets = img.points.map((p, pi) => ({
      text: p,
      options: { bullet: true, breakLine: pi < img.points.length - 1 }
    }));
    slide.addText(bullets, {
      x: x + 0.1, y: y + 0.35, w: 4.45, h: 1.65,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 12 — LAB WORKUP
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Diagnosis — Laboratory & Cardiac Workup");

  card(slide, 0.25, 0.85, 4.55, 3.7, "FFFFFF", C.navyLight);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 0.85, w: 4.55, h: 0.35,
    fill: { color: C.navyLight }, line: { color: C.navyLight }
  });
  slide.addText("IMMEDIATE LABORATORY TESTS", {
    x: 0.25, y: 0.85, w: 4.55, h: 0.35,
    fontSize: 12, bold: true, color: C.white,
    fontFace: "Calibri", align: "center", valign: "middle"
  });
  const labs = [
    "Glucose (fingerstick — treat hypo/hyperglycemia first)",
    "CBC (thrombocytopenia, polycythemia)",
    "PT / INR / aPTT (anticoagulant status, coagulopathy)",
    "BMP (electrolytes, renal function)",
    "Troponin (concurrent MI in 3–20%)",
    "12-lead ECG (AFib, ST changes, arrhythmias)",
    "Lipid panel, HbA1c",
    "Blood cultures (if endocarditis suspected)",
  ];
  labs.forEach((l, i) => {
    slide.addText(`• ${l}`, {
      x: 0.38, y: 1.25 + i * 0.41, w: 4.3, h: 0.38,
      fontSize: 11, color: C.navy, fontFace: "Calibri"
    });
  });

  card(slide, 5.2, 0.85, 4.55, 3.7, "FFFFFF", C.red);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 5.2, y: 0.85, w: 4.55, h: 0.35,
    fill: { color: C.red }, line: { color: C.red }
  });
  slide.addText("CARDIAC & VASCULAR WORKUP", {
    x: 5.2, y: 0.85, w: 4.55, h: 0.35,
    fontSize: 12, bold: true, color: C.white,
    fontFace: "Calibri", align: "center", valign: "middle"
  });
  const cardiac = [
    ["Cardiac monitoring", "Continuous ≥48 hours to detect paroxysmal AFib"],
    ["Echocardiography", "Identify mural thrombus, PFO, valvular disease"],
    ["Holter / event monitor", "Prolonged AFib surveillance (ambulatory)"],
    ["Carotid Doppler / CTA", "Carotid stenosis — done before discharge in TIA"],
    ["MRA / CTA of vessels", "Dissection, intracranial atherosclerosis, aneurysm"],
    ["LP (xanthochromia)", "SAH if CT negative but clinical suspicion high"],
  ];
  cardiac.forEach((c, i) => {
    slide.addText(c[0], {
      x: 5.35, y: 1.25 + i * 0.56, w: 1.9, h: 0.28,
      fontSize: 11, bold: true, color: C.red, fontFace: "Calibri"
    });
    slide.addText(c[1], {
      x: 5.35, y: 1.52 + i * 0.56, w: 4.25, h: 0.28,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });

  // Time is brain
  card(slide, 0.25, 4.72, 9.5, 0.54, C.red, C.red);
  slide.addText('⏱  "TIME IS BRAIN" — Every 15 minutes of delay to treatment = ~120 million neurons lost', {
    x: 0.4, y: 4.74, w: 9.2, h: 0.48,
    fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", align: "center"
  });
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: ACUTE MANAGEMENT
// ════════════════════════════════════════════════════════════════
sectionSlide("08  Acute Management", "Ischemic Stroke");

// ════════════════════════════════════════════════════════════════
//  SLIDE 13 — ACUTE ISCHEMIC GENERAL MANAGEMENT
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Acute Ischemic Stroke — General Management (ABCs)");

  const mgmt = [
    { icon: "A", title: "Airway & Breathing", color: C.navyLight, items: ["Maintain O₂ sat >94%; avoid supplemental O₂ if sat normal", "Intubate if GCS ≤8 or airway at risk", "Head of bed ≥30° to prevent aspiration", "Aspiration pneumonia mortality: 15–25%"] },
    { icon: "B", title: "Blood Pressure", color: C.red, items: ["Do NOT lower BP below 220/120 mmHg (ischemic)", "If tPA eligible: maintain <185/110 mmHg before, <180/105 after", "Avoid hypotension — collateral flow depends on BP", "Preferred IV agents: labetalol, nicardipine"] },
    { icon: "G", title: "Glucose", color: C.orange, items: ["Target: 60–180 mg/dL (avoid hypo- AND hyperglycemia)", "Treat immediately if glucose <60 or >180 mg/dL", "Intensive glucose control NOT beneficial (SHINE trial)", "Hyperglycemia worsens ischemic injury"] },
    { icon: "T", title: "Temperature", color: C.tealDark, items: ["Fever worsens ischemic outcome — treat aggressively", "Target normothermia with antipyretics + surface cooling", "Mild hypothermia is neuroprotective (not routine practice)", "Identify source of fever (aspiration, UTI, DVT)"] },
  ];

  mgmt.forEach((m, i) => {
    const x = 0.25 + (i % 2) * 4.88;
    const y = i < 2 ? 0.85 : 3.0;
    card(slide, x, y, 4.65, 2.0, "FFFFFF", m.color);
    // Icon circle
    slide.addShape(pres.shapes.ELLIPSE, {
      x: x + 0.12, y: y + 0.07, w: 0.42, h: 0.42,
      fill: { color: m.color }, line: { color: m.color }
    });
    slide.addText(m.icon, {
      x: x + 0.12, y: y + 0.07, w: 0.42, h: 0.42,
      fontSize: 16, bold: true, color: C.white,
      fontFace: "Calibri", align: "center", valign: "middle"
    });
    slide.addText(m.title, {
      x: x + 0.62, y: y + 0.07, w: 3.9, h: 0.42,
      fontSize: 13, bold: true, color: m.color, fontFace: "Calibri", valign: "middle"
    });
    const bullets = m.items.map((item, ii) => ({
      text: item,
      options: { bullet: true, breakLine: ii < m.items.length - 1 }
    }));
    slide.addText(bullets, {
      x: x + 0.15, y: y + 0.52, w: 4.4, h: 1.42,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });

  // DVT note
  card(slide, 0.25, 5.1, 9.5, 0.4, "EAF4FF", C.navyLight);
  slide.addText("DVT Prevention: Subcutaneous heparin (unfractionated or LMWH) + Pneumatic compression stockings — start immediately", {
    x: 0.38, y: 5.12, w: 9.2, h: 0.35,
    fontSize: 10, color: C.navyLight, fontFace: "Calibri"
  });
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 14 — THROMBOLYSIS
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Acute Ischemic Stroke — IV Thrombolysis (tPA)");

  // tPA box
  card(slide, 0.25, 0.85, 5.9, 2.15, "FFFFFF", C.red);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 0.85, w: 5.9, h: 0.35,
    fill: { color: C.red }, line: { color: C.red }
  });
  slide.addText("IV ALTEPLASE (tPA) — DOSING & TIMING", {
    x: 0.35, y: 0.85, w: 5.7, h: 0.35,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  slide.addText([
    { text: "Dose: ", options: { bold: true } },
    { text: "0.9 mg/kg IV (max 100 mg)\n", options: {} },
    { text: "Administration: ", options: { bold: true } },
    { text: "10% as IV bolus → remaining 90% over 60 min\n", options: {} },
    { text: "Window: ", options: { bold: true } },
    { text: "≤4.5 hours from symptom onset\n", options: {} },
    { text: "BP requirement: ", options: { bold: true } },
    { text: "<185/110 mmHg BEFORE; <180/105 during/after\n", options: {} },
    { text: "Goal door-to-needle: ", options: { bold: true } },
    { text: "≤60 min (target ≤45 min)\n", options: {} },
    { text: "Risk of symptomatic ICH: ", options: { bold: true } },
    { text: "2–7%", options: {} },
  ], { x: 0.38, y: 1.23, w: 5.65, h: 1.7, fontSize: 11, color: C.navy, fontFace: "Calibri" });

  // Tenecteplase note
  card(slide, 6.4, 0.85, 3.35, 2.15, "FFF8EC", C.orange);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 6.4, y: 0.85, w: 3.35, h: 0.35,
    fill: { color: C.orange }, line: { color: C.orange }
  });
  slide.addText("TENECTEPLASE", {
    x: 6.5, y: 0.85, w: 3.15, h: 0.35,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  slide.addText("• Single IV bolus (0.25 mg/kg, max 25 mg)\n• Equal or superior efficacy in some trials\n• Simpler administration\n• Increasingly preferred in LVO patients prior to thrombectomy", {
    x: 6.5, y: 1.23, w: 3.15, h: 1.7,
    fontSize: 10, color: C.navy, fontFace: "Calibri"
  });

  // Contraindications
  card(slide, 0.25, 3.1, 5.9, 2.15, "FFF0EE", C.red);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 3.1, w: 5.9, h: 0.32,
    fill: { color: C.red }, line: { color: C.red }
  });
  slide.addText("KEY CONTRAINDICATIONS TO tPA", {
    x: 0.35, y: 3.1, w: 5.7, h: 0.32,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  const contra = [
    "Hemorrhage on CT / active internal bleeding",
    "BP >185/110 mmHg (that cannot be controlled)",
    "Recent major surgery or trauma (<3 months)",
    "Prior ICH or structural CNS lesion",
    "INR >1.7 / platelet count <100,000",
    "Current anticoagulation (DOAC within 48h)",
    "Blood glucose <50 or >400 mg/dL",
  ];
  contra.forEach((c, i) => {
    slide.addText(`✗  ${c}`, {
      x: 0.38, y: 3.47 + i * 0.27, w: 5.65, h: 0.26,
      fontSize: 10, color: C.red, fontFace: "Calibri"
    });
  });

  // Mild/disabling note
  card(slide, 6.4, 3.1, 3.35, 2.15, "EAF4FF", C.navyLight);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 6.4, y: 3.1, w: 3.35, h: 0.32,
    fill: { color: C.navyLight }, line: { color: C.navyLight }
  });
  slide.addText("SPECIAL CASES", {
    x: 6.5, y: 3.1, w: 3.15, h: 0.32,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  slide.addText("• Mild non-disabling: tPA NOT recommended\n• Mild DISABLING: tPA recommended within 4.5h\n• Extended window (4.5–9h): MRI DWI/FLAIR mismatch criterion\n• Wake-up stroke: treat by perfusion imaging criteria", {
    x: 6.5, y: 3.46, w: 3.15, h: 1.72,
    fontSize: 10, color: C.navy, fontFace: "Calibri"
  });
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 15 — MECHANICAL THROMBECTOMY
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Acute Ischemic Stroke — Mechanical Thrombectomy (EVT)");

  // Main criteria box
  card(slide, 0.25, 0.85, 9.5, 1.6, "FFFFFF", C.navyLight);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 0.85, w: 9.5, h: 0.35,
    fill: { color: C.navyLight }, line: { color: C.navyLight }
  });
  slide.addText("ENDOVASCULAR THROMBECTOMY (EVT) — Target Vessels & Time Windows", {
    x: 0.35, y: 0.85, w: 9.3, h: 0.35,
    fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });

  const windows = [
    { time: "0–6 h", label: "Standard window", desc: "IV tPA first (if eligible)\n→ CTA → EVT if ICA/M1-M2/basilar occlusion", color: C.green },
    { time: "6–24 h", label: "Extended window", desc: "CTA/CTP perfusion mismatch\nDAWN or DEFUSE-3 criteria\ntPA NOT given", color: C.orange },
  ];
  windows.forEach((w, i) => {
    const x = 0.4 + i * 4.8;
    slide.addShape(pres.shapes.RECTANGLE, {
      x, y: 1.25, w: 0.75, h: 0.75,
      fill: { color: w.color }, line: { color: w.color }
    });
    slide.addText(w.time, {
      x, y: 1.25, w: 0.75, h: 0.75,
      fontSize: 10, bold: true, color: C.white, fontFace: "Calibri",
      align: "center", valign: "middle"
    });
    slide.addText(w.label, {
      x: x + 0.85, y: 1.25, w: 3.7, h: 0.3,
      fontSize: 12, bold: true, color: w.color, fontFace: "Calibri"
    });
    slide.addText(w.desc, {
      x: x + 0.85, y: 1.55, w: 3.7, h: 0.65,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });

  // Key points
  const evtPoints = [
    { title: "Target Vessels", body: "ICA (terminus), M1 or M2 MCA, Basilar artery, Vertebral artery" },
    { title: "Technical Success", body: "mTICI ≥2b reperfusion is the goal; stent retrievers + aspiration catheters" },
    { title: "Combine with tPA", body: "Bridging tPA + EVT is recommended if both eligible; do NOT delay tPA for CTA" },
    { title: "Outcomes", body: "NNT ~2.6 for functional independence in LVO; most impactful treatment for large strokes" },
    { title: "Posterior Circulation", body: "Basilar artery thrombosis: EVT up to 24h (high mortality without treatment)" },
    { title: "Time Goal", body: "Door-to-groin puncture ≤60 min; every 20 min delay = 1% less functional independence" },
  ];
  evtPoints.forEach((p, i) => {
    const x = 0.25 + (i % 3) * 3.25;
    const y = 2.6 + Math.floor(i / 3) * 1.22;
    card(slide, x, y, 3.1, 1.1, "FFFFFF", C.navyLight);
    slide.addText(p.title, {
      x: x + 0.12, y: y + 0.08, w: 2.86, h: 0.3,
      fontSize: 11, bold: true, color: C.navyLight, fontFace: "Calibri"
    });
    slide.addText(p.body, {
      x: x + 0.12, y: y + 0.38, w: 2.86, h: 0.65,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: HEMORRHAGIC MANAGEMENT
// ════════════════════════════════════════════════════════════════
sectionSlide("09  Acute Management", "Hemorrhagic Stroke (ICH & SAH)");

// ════════════════════════════════════════════════════════════════
//  SLIDE 16 — ICH MANAGEMENT
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Acute Hemorrhagic Stroke — ICH Management");

  const ichSections = [
    {
      title: "Blood Pressure Control",
      color: C.red,
      body: "• SBP 150–220: acute lowering to <140 mmHg within 1 hour is safe & may limit hematoma expansion\n• SBP >220: use continuous IV infusion (nicardipine, labetalol)\n• Avoid SBP drops >25% in first hour",
    },
    {
      title: "Anticoagulation Reversal",
      color: C.orange,
      body: "• Warfarin: PCC (prothrombin complex concentrate) + Vit K — preferred over FFP\n  (faster INR correction, lower volume, lower infection risk)\n• Dabigatran: Idarucizumab (Praxbind) 5g IV\n• Xa inhibitors (apixaban/rivaroxaban): Andexanet alfa\n• Heparin: Protamine sulfate",
    },
    {
      title: "ICP Management",
      color: C.navyLight,
      body: "• Head of bed 30°\n• Osmotic therapy: Mannitol (0.25–1 g/kg) or Hypertonic saline (23.4%)\n• Hyperventilation (target pCO₂ 30–35): temporizing measure only\n• EVD (external ventricular drain) for hydrocephalus\n• Avoid hypotonic fluids",
    },
    {
      title: "Surgical Intervention",
      color: C.tealDark,
      body: "• Cerebellar hemorrhage >3 cm with brainstem compression or hydrocephalus → urgent evacuation\n• Supratentorial ICH: surgery controversial; selected patients with lobar hemorrhage\n• Decompressive craniectomy for malignant MCA infarction (large ischemic +edema)\n• SAH: surgical clipping or endovascular coiling of ruptured aneurysm",
    },
  ];

  ichSections.forEach((s, i) => {
    const x = 0.25 + (i % 2) * 4.88;
    const y = i < 2 ? 0.85 : 3.0;
    card(slide, x, y, 4.65, 2.05, "FFFFFF", s.color);
    slide.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 4.65, h: 0.32,
      fill: { color: s.color }, line: { color: s.color }
    });
    slide.addText(s.title, {
      x: x + 0.1, y, w: 4.45, h: 0.32,
      fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
    });
    slide.addText(s.body, {
      x: x + 0.12, y: y + 0.35, w: 4.4, h: 1.65,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });

  // Key contraindication
  card(slide, 0.25, 5.12, 9.5, 0.42, "FFF0EE", C.red);
  slide.addText("✗  NO tPA / antithrombotic / anticoagulant in hemorrhagic stroke.  Reversal agents are the priority.", {
    x: 0.38, y: 5.14, w: 9.2, h: 0.36,
    fontSize: 11, bold: true, color: C.red, fontFace: "Calibri"
  });
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: SECONDARY PREVENTION
// ════════════════════════════════════════════════════════════════
sectionSlide("10  Secondary Prevention", "Preventing recurrent stroke");

// ════════════════════════════════════════════════════════════════
//  SLIDE 17 — SECONDARY PREVENTION
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Secondary Prevention of Stroke");

  const prevSections = [
    {
      title: "Antiplatelet Therapy",
      color: C.navyLight,
      sub: "(Non-cardioembolic ischemic stroke)",
      body: [
        "Aspirin 75–100 mg/day — first-line",
        "Dual antiplatelet (aspirin + clopidogrel or ticagrelor) for 21–30 days after minor stroke/TIA, then aspirin alone",
        "Clopidogrel: 75 mg/day (alternative to aspirin)",
        "Ticagrelor: not affected by CYP2C19 polymorphisms (advantage over clopidogrel)",
      ],
    },
    {
      title: "Anticoagulation",
      color: C.red,
      sub: "(Cardioembolic — Atrial Fibrillation)",
      body: [
        "DOACs preferred over warfarin (lower ICH risk, no INR monitoring)",
        "Apixaban 5 mg BID (2.5 mg BID if impaired renal function)",
        "Rivaroxaban, dabigatran, edoxaban also used",
        "Timing: start 2–14 days post-stroke (balance hemorrhagic transformation risk)",
        "Warfarin (INR 2–3) if DOAC contraindicated",
      ],
    },
    {
      title: "BP & Lipid Management",
      color: C.tealDark,
      sub: "(All ischemic stroke patients)",
      body: [
        "BP target: <130/80 mmHg (restart antihypertensives 24–48h post-stroke)",
        "High-intensity statin therapy regardless of LDL level",
        "Statin reduces recurrent stroke by ~25–35%",
        "Ezetimibe add-on if LDL target not reached",
      ],
    },
    {
      title: "Carotid Revascularization",
      color: C.orange,
      sub: "(Symptomatic carotid stenosis)",
      body: [
        "Symptomatic stenosis 50–70%: CEA + medical therapy (NNT = 6)",
        "Symptomatic stenosis ≥70%: CEA strongly recommended, ideally within 2 weeks",
        "Carotid artery stenting (CAS): alternative in high surgical risk patients",
        "Intracranial stenting: reserved for recurrent stroke on optimal medical therapy",
      ],
    },
  ];

  prevSections.forEach((s, i) => {
    const x = 0.25 + (i % 2) * 4.88;
    const y = i < 2 ? 0.85 : 3.05;
    card(slide, x, y, 4.65, 2.05, "FFFFFF", s.color);
    slide.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 4.65, h: 0.35,
      fill: { color: s.color }, line: { color: s.color }
    });
    slide.addText(s.title, {
      x: x + 0.1, y, w: 4.45, h: 0.35,
      fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
    });
    slide.addText(s.sub, {
      x: x + 0.12, y: y + 0.38, w: 4.4, h: 0.25,
      fontSize: 9, color: s.color, fontFace: "Calibri", italic: true
    });
    const bullets = s.body.map((item, ii) => ({
      text: item,
      options: { bullet: true, breakLine: ii < s.body.length - 1 }
    }));
    slide.addText(bullets, {
      x: x + 0.12, y: y + 0.62, w: 4.4, h: 1.35,
      fontSize: 10, color: C.navy, fontFace: "Calibri"
    });
  });

  // Lifestyle
  card(slide, 0.25, 5.15, 9.5, 0.38, "EAF4FF", C.navyLight);
  slide.addText("Lifestyle: Smoking cessation  •  BP monitoring at home  •  Regular physical activity  •  Mediterranean diet  •  Moderate alcohol (<2 units/day)  •  Weight management",
    { x: 0.38, y: 5.17, w: 9.2, h: 0.32, fontSize: 10, color: C.navyLight, fontFace: "Calibri", align: "center" }
  );
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: COMPLICATIONS
// ════════════════════════════════════════════════════════════════
sectionSlide("11  Complications", "Neurological and systemic");

// ════════════════════════════════════════════════════════════════
//  SLIDE 18 — COMPLICATIONS
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Complications of Stroke");

  const comps = [
    {
      title: "Cerebral Edema",
      color: C.red,
      body: "Peaks day 2–3 (up to 10 days). Cytotoxic then vasogenic. Largest risk in young patients and large MCA infarcts. May cause herniation. Treat: mannitol, hypertonic saline; hemicraniectomy for malignant MCA infarction.",
    },
    {
      title: "Hemorrhagic Transformation",
      color: C.orange,
      body: "Ischemic brain reperfusion can lead to petechial or frank hemorrhage. Risk increased with tPA, large infarcts, early anticoagulation. Symptomatic HT with tPA = 2–7%. Monitor with 24h CT post-tPA.",
    },
    {
      title: "Aspiration Pneumonia",
      color: C.navyLight,
      body: "Mortality 15–25%. Common due to dysphagia. Documented in >1/3 of brainstem strokes, 1/4 of bilateral hemispheric, 1/10 of unilateral strokes. Mandatory: swallow screen before oral intake; NPO until speech therapy evaluation.",
    },
    {
      title: "Post-Stroke Seizures & Epilepsy",
      color: C.tealDark,
      body: "Most common cause of new seizures in elderly. Early seizures (<2 weeks): don't require long-term AED. Chronic epilepsy risk: 16–17x increased. ~30% of early seizures → late epilepsy. Higher risk with cortical and hemorrhagic strokes.",
    },
    {
      title: "DVT & Pulmonary Embolism",
      color: C.grayDark,
      body: "Bedridden patients at high risk. Pneumatic compression stockings proven beneficial. Subcutaneous LMWH or UFH are safe. Avoid therapeutic anticoagulation acutely unless PE confirmed.",
    },
    {
      title: "Post-Stroke Depression",
      color: C.navy,
      body: "Affects ~30% of patients. Worsens rehabilitation outcomes and mortality. Screen all patients. SSRIs (escitalopram, fluoxetine) are first-line treatment. Early mobilization and psychological support are protective.",
    },
  ];

  comps.forEach((c, i) => {
    const x = 0.25 + (i % 3) * 3.25;
    const y = i < 3 ? 0.85 : 3.1;
    card(slide, x, y, 3.1, 2.1, "FFFFFF", c.color);
    slide.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 3.1, h: 0.3,
      fill: { color: c.color }, line: { color: c.color }
    });
    slide.addText(c.title, {
      x: x + 0.08, y, w: 2.95, h: 0.3,
      fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
    });
    slide.addText(c.body, {
      x: x + 0.08, y: y + 0.33, w: 2.95, h: 1.72,
      fontSize: 9.5, color: C.navy, fontFace: "Calibri"
    });
  });
}

// ════════════════════════════════════════════════════════════════
//  SECTION DIVIDER: REHABILITATION
// ════════════════════════════════════════════════════════════════
sectionSlide("12  Rehabilitation & Prognosis", "Recovery, neuroplasticity & outcome");

// ════════════════════════════════════════════════════════════════
//  SLIDE 19 — REHABILITATION
// ════════════════════════════════════════════════════════════════
{
  const slide = contentSlide("Rehabilitation & Prognosis");

  // Stroke unit benefit
  card(slide, 0.25, 0.85, 9.5, 0.95, "EAF4FF", C.navyLight);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 0.85, w: 9.5, h: 0.32,
    fill: { color: C.navyLight }, line: { color: C.navyLight }
  });
  slide.addText("STROKE UNIT CARE — Evidence Base", {
    x: 0.35, y: 0.85, w: 9.3, h: 0.32,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  slide.addText("Dedicated stroke unit care vs. general ward: Lower mortality  •  Shorter hospital stay  •  Reduced discharge to nursing home  •  Lower rate of complications",
    { x: 0.38, y: 1.18, w: 9.2, h: 0.55, fontSize: 11, color: C.navy, fontFace: "Calibri" }
  );

  // Rehab disciplines
  const rehabItems = [
    { icon: "PT", title: "Physical Therapy", body: "Motor recovery, balance, gait retraining\nEarly mobilization within 24–48h if hemodynamically stable" },
    { icon: "OT", title: "Occupational Therapy", body: "ADL retraining, fine motor coordination\nHome modifications, adaptive equipment" },
    { icon: "ST", title: "Speech Therapy", body: "Aphasia therapy, dysphagia evaluation (MBSS)\nCognitive-communication rehabilitation" },
    { icon: "Psy", title: "Psychological Support", body: "Screen for post-stroke depression (PHQ-9)\nSSRI therapy, cognitive rehabilitation" },
  ];
  rehabItems.forEach((r, i) => {
    const x = 0.25 + i * 2.4;
    card(slide, x, 2.0, 2.2, 1.85, "FFFFFF", C.tealDark);
    slide.addShape(pres.shapes.ELLIPSE, {
      x: x + 0.72, y: 2.08, w: 0.72, h: 0.72,
      fill: { color: C.tealDark }, line: { color: C.tealDark }
    });
    slide.addText(r.icon, {
      x: x + 0.72, y: 2.08, w: 0.72, h: 0.72,
      fontSize: 13, bold: true, color: C.white, fontFace: "Calibri",
      align: "center", valign: "middle"
    });
    slide.addText(r.title, {
      x, y: 2.83, w: 2.2, h: 0.3,
      fontSize: 11, bold: true, color: C.tealDark, fontFace: "Calibri", align: "center"
    });
    slide.addText(r.body, {
      x: x + 0.1, y: 3.15, w: 2.0, h: 0.65,
      fontSize: 9.5, color: C.navy, fontFace: "Calibri", align: "center"
    });
  });

  // Neuroplasticity
  card(slide, 0.25, 4.0, 4.55, 1.25, "FFFFFF", C.orange);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0.25, y: 4.0, w: 4.55, h: 0.3,
    fill: { color: C.orange }, line: { color: C.orange }
  });
  slide.addText("NEUROPLASTICITY", {
    x: 0.35, y: 4.0, w: 4.35, h: 0.3,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  slide.addText("Greatest recovery window: first 3–6 months post-stroke. Axonal sprouting, synaptic remodeling, and cortical remapping support functional recovery. Constraint-induced movement therapy (CIMT) exploits neuroplasticity.", {
    x: 0.38, y: 4.33, w: 4.3, h: 0.85,
    fontSize: 10, color: C.navy, fontFace: "Calibri"
  });

  // Prognosis factors
  card(slide, 5.2, 4.0, 4.55, 1.25, "FFFFFF", C.red);
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 5.2, y: 4.0, w: 4.55, h: 0.3,
    fill: { color: C.red }, line: { color: C.red }
  });
  slide.addText("POOR PROGNOSIS FACTORS", {
    x: 5.3, y: 4.0, w: 4.35, h: 0.3,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  slide.addText("High NIHSS  •  Large infarct volume  •  Advanced age  •  Fever / hyperglycemia on admission  •  Concurrent cardiac failure  •  Hemorrhagic transformation  •  Delayed treatment", {
    x: 5.33, y: 4.33, w: 4.3, h: 0.85,
    fontSize: 10, color: C.navy, fontFace: "Calibri"
  });
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 20 — SUMMARY / CONCLUSION
// ════════════════════════════════════════════════════════════════
{
  const slide = pres.addSlide();
  darkBg(slide);

  slide.addShape(pres.shapes.RECTANGLE, {
    x: 6.5, y: -0.5, w: 4, h: 7,
    fill: { color: C.navyMid }, line: { color: C.navyMid },
    rotate: 12
  });
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 4.8, w: 10, h: 0.825,
    fill: { color: C.red }, line: { color: C.red }
  });

  slide.addText("KEY TAKEAWAYS", {
    x: 0.5, y: 0.25, w: 8, h: 0.55,
    fontSize: 30, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 4
  });

  const takeaways = [
    ["Time is brain", "Every minute without reperfusion = ~2 million neurons lost"],
    ["Non-contrast CT first", "Always rule out hemorrhage before thrombolysis or anticoagulation"],
    ["tPA within 4.5 h", "0.9 mg/kg IV; door-to-needle goal ≤60 min (target ≤45 min)"],
    ["EVT for LVO", "Up to 24 h with perfusion imaging; most impactful treatment for large strokes"],
    ["ICH: reverse & control", "PCC for warfarin reversal; BP <140 mmHg within 1 h"],
    ["Secondary prevention", "AFib → anticoagulate; carotid stenosis → CEA; all patients → statins + BP control"],
    ["Stroke unit care", "Reduces mortality, complications, and disability — always admit to dedicated unit"],
  ];

  takeaways.forEach((t, i) => {
    slide.addShape(pres.shapes.RECTANGLE, {
      x: 0.5, y: 0.9 + i * 0.52, w: 0.06, h: 0.35,
      fill: { color: C.red }, line: { color: C.red }
    });
    slide.addText(t[0] + ": ", {
      x: 0.66, y: 0.9 + i * 0.52, w: 2.1, h: 0.35,
      fontSize: 12, bold: true, color: C.teal,
      fontFace: "Calibri", valign: "middle"
    });
    slide.addText(t[1], {
      x: 2.76, y: 0.9 + i * 0.52, w: 5.8, h: 0.35,
      fontSize: 12, color: C.white,
      fontFace: "Calibri", valign: "middle"
    });
  });

  slide.addText("Harrison's 22e  |  Bradley & Daroff's Neurology  |  Rosen's Emergency Medicine 9e  |  Adams & Victor's 12e", {
    x: 0.3, y: 4.83, w: 9.4, h: 0.75,
    fontSize: 10, color: C.white,
    fontFace: "Calibri", valign: "middle", align: "center"
  });
}

// ════════════════════════════════════════════════════════════════
//  WRITE FILE
// ════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/stroke-ppt/Stroke_Comprehensive.pptx" })
  .then(() => console.log("SUCCESS: /home/daytona/workspace/stroke-ppt/Stroke_Comprehensive.pptx"))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/stroke-ppt/stroke.js'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/stroke-ppt/stroke.js'